Methods for treating cancer

ABSTRACT

The present invention relates to methods of treating patients with advanced forms of cancer, such as clear cell renal cell carcinoma, in which X4P-001 is administered in order to reduce angiogenic escape that typically occurs with TKI therapy. The methods demonstrate surprising results, including regression of tumor size and cell number, with comparatively little toxicity.

CROSS-REFERENCE TO RELATED APPLICATIONS

This application claims the benefit of priority to U.S. Provisional Patent Application Ser. No. 62/267,052, filed Dec. 14, 2015, the entirety of which is hereby incorporated by reference.

STATEMENT OF GOVERNMENT SUPPORT

Aspects of this invention were made with government support under Grant No. P50CA101942 awarded by the National Cancer Institute. The United States Government has certain rights in this invention.

FIELD OF THE INVENTION

The present invention relates to methods for treating cancer, in particular, methods for overcoming resistance to treatment with VEGF-R antagonists in cancers, such as renal cell carcinoma.

BACKGROUND OF THE INVENTION

In ˜75% of patients with sporadic clear-cell renal cell carcinoma (ccRCC) there is functional loss of the VHL gene, typically by mutation, but also silencing by hypermethylation. VHL encodes the von Hippel-Lindau tumor suppression protein, which mediates proteolytic degradation of the hypoxia-inducible factor (HIF)-α [2]. Loss of this function results in increased levels of HIF-α, increased expression of VEGF, tumor angiogenesis, and, ultimately, the hypervascularity characteristic of these malignancies. Multiple agents that block the activation of the VEGF pathway have been shown to improve outcomes, including tyrosine kinase inhibitors (TKIs), such as sunitinib, axitinib, sorafenib or pazopanib, that block the VEGF signaling pathway and bevacizumab, a monoclonal antibody, that binds circulating VEGF and thus prevents the ligand from binding to the VEGF receptor.

Despite the demonstrated benefits of such angiogenesis inhibitors in ccRCC, the approach is not curative. Although many patients respond initially, most of them experience relapse and progression. There is a clear unmet need for agents that improve outcomes by preventing or delaying treatment resistance.

BRIEF DESCRIPTION OF THE FIGURES

FIGS. 1A and 1B illustrates the increase in tumor regression observed in two murine models of tumor xenografts that have been treated with a combination of X4P-001 and axitinib, as described in Example 1. FIG. 1A shows the relative effects on tumor volume of treatment of murine 786-0 xenografts in mice treated with control, axitinib or X4P-001 as single agents, and with a combination of X4P-001 and axitinib. FIG. 1B shows the relative effects on tumor volume of treatment of murine A498 xenografts with control, axitinib or X4P-001 as single agents, and with a combination of X4P-001 and axitinib. Treatment was initiated when tumor nodules reached ˜7 mm mean diameter.

FIGS. 2A-2D illustrate the increase in tumor cell death observed in the murine 786-0 xenograft model described in Example 1 in mice treated with control (FIG. 2A), axitinib (FIG. 2B) or X4P-001 (FIG. 2C) as single agents, or with a combination of X4P-001 and axitinib (FIG. 2D).

FIG. 3A-3D illustrate the increase in tumor cell death observed in the murine 498 xenograft model described in Example 1 in mice treated with control (FIG. 3A), axitinib (FIG. 3B) or X4P-001 (FIG. 3C) as single agents, or with a combination of X4P-001 and axitinib (FIG. 3D).

FIGS. 4A-4D illustrate the decreased presence of Ki-67+ and CD34+ cells observed in two murine models of tumor xenografts described in Example 1 that have been treated with a combination of X4P-001 and axitinib. FIG. 4A shows the relative preponderance of expression of Ki-67 by tumor cells in the murine 786-0 xenograft model after treatment with control, axitinib or X4P-001 as single agents, and with a combination of X4P-001 and axitinib. FIG. 4B shows the relative preponderance of expression of CD34 by tumor cells in the murine 786-0 xenograft model after treatment with control, axitinib or X4P-001 as single agents, and with a combination of X4P-001 and axitinib. FIG. 4C shows the relative preponderance of expression of Ki-67 by tumor cells in the murine A498 xenograft model after treatment with control, axitinib or X4P-001 as single agents, and with a combination of X4P-001 and axitinib. FIG. 4D shows the relative preponderance of expression of CD34 by tumor cells in the murine A498 xenograft model after treatment with control, axitinib or X4P-001 as single agents, and with a combination of X4P-001 and axitinib. In all instances, the reduction in expression of Ki-67 and CD34 was significantly reduced (p<0.05) in mice treated with the combination compared to mice treated with X4P-001.

FIGS. 5A-5D illustrate the significantly reduced MDSC infiltration observed in two murine models of tumor xenografts described in Example 1 in mice that have been treated with a combination of X4P-001 and axitinib. FIG. 5A shows the relative reduction in area of MDSC infiltration in xenografts in the murine 786-0 xenograft model after treatment with control, axitinib or X4P-001 as single agents, and with a combination of X4P-001 and axitinib. FIG. 5B shows the relative reduction in area of MDSC infiltration in xenografts in the murine A498 xenograft model after treatment with control, axitinib or X4P-001 as single agents, and with a combination of X4P-001 and axitinib. FIG. 5C shows the relative number of MDSC (CD11b+GR-1+) cells infiltrating xenografts in the murine 786-0 xenograft model after treatment with control, axitinib or X4P-001 as single agents, and with a combination of X4P-001 and axitinib. FIG. 5D shows the relative number of MDSC (CD11b+GR-1+) cells infiltrating xenografts in the murine A498 xenograft model after treatment with control, axitinib or X4P-001 as single agents, and with a combination of X4P-001 and axitinib.

FIG. 6 and FIG. 7 illustrate through immunofluorescence (IF) the MDSC (CD11b+GR-1+) infiltrating 786-0 xenografts treated with axitinib alone under low power (FIG. 6) and high power (FIG. 7), respectively.

FIG. 8 illustrates a process flow diagram for manufacturing 200 mg X4P-001 Capsules.

FIG. 9 illustrates measurements of X4P-001 200 mg capsule fills vs. theoretical capsule fill.

FIG. 10 illustrates the dissolution profile of the developed X4P-001 200 mg capsules vs. the dissolution profile of the X4P-001 100 mg capsules.

FIG. 11 illustrates Western blots of 786 xenografts treated with X4P-001 showed reduction in the level of HIF-2α relative to that caused by axitinib treatment.

FIG. 12 illustrates that axitinib suppressed the micro-RNAs mir-30a and mir-30c, and the addition of X4P-001 to axitinib resulted in increased mir-30a and mir-30c after 8 days of treatment (786-0 xenograft tumor). mir-30a and mir-30c microRNA and HIF-2α mRNA expression from tumors of xenografts treated with axitinib +/−X4P-001. Data is presented as mir-30a or mir-30c expression relative to the mean control value (left side) and relative HIF-2α RNA expression.

FIG. 13 illustrates that axitinib and X4P-001 together act to reduce HIF-2a expression after 8 days of treatment in 786 xenograft tumors.

FIGS. 14A-C illustrate the effect of X4P-001 treatment on 786 hypoxic cells in vitro on mir-30a and mir-30c induction and HIF-2α reduction. FIG. 14A shows a Western blot of 786 cells treated with X4P-001 for 24 hours in normoxic and hypoxic (1% O₂) conditions. FIG. 14B illustrates mir-30a and mir-30c microRNA and (FIG. 14C) total HIF-2α RNA expression from the same cells from FIG. 14A.

FIG. 15A illustrates Western blot results from lysates of A375 cells or A375 cells transfected with a constitutively active Stat3 construct. Cells were treated with X4P-001 for 24 h in normoxic or hypoxic conditions. FIG. 15B shows mir-30c microRNA and FIG. 15C shows total RNA expression from the same cells from FIG. 15A. The suppression of HIF-2α and induction of mir-30a and 30c is thus dependent on Stat3 expression. Stat3 is known to be important in promoting CXCL12-mediated invasion of tumors.

FIG. 16 illustrates particle size distribution of the X4P-001 batch used in developing the 10 mg, 25 mg, and 100 mg capsules.

DETAILED DESCRIPTION OF CERTAIN EMBODIMENTS OF THE INVENTION

CXCR4 (C-X-C chemokine receptor type 4) is the receptor for CXCL12 (C-X-C chemokine ligand type 12; also referred to as SDF-1α, stromal-derived-factor 1α). CXCL12 has potent chemotactic activity for lymphocytes and MDSCs (myeloid-derived suppressor cells), and is important in homing of hematopoietic stem cells to the bone marrow. CXCR4 is also expressed and active on multiple types of human cancers, including ccRCC, ovarian cancer, and melanoma, and increased expression of CXCR4 on tumor cells has been associated with significantly decreased overall patient survival [3, 4, 5, 6].

Multiple observations implicate the CXCL12/CXCR4 axis in contributing to the lack (or loss) of tumor responsiveness to angiogenesis inhibitors (also referred to as “angiogenic escape”). In animal cancer models, interference with CXCR4 function has been demonstrated to disrupt the tumor microenvironment (TME) and unmask the tumor to immune attack by multiple mechanisms, including eliminating tumor re-vascularization [7,8], and increasing the ratio of CD8+ T cells to Treg cells [7, 9, 10]. These effects result in significantly decreased tumor burden and increased overall survival in xenograft, syngeneic, as well as transgenic, cancer models [7, 9, 8].

X4P-001 is a potent, orally bioavailable CXCR4 antagonist [11], that has demonstrated activity in solid and liquid tumor models [12, and unpublished data] and has previously (under the designations AMD070 and AMD11070) been in Phase 1 and 2a trials involving a total of 71 healthy volunteers [11, 13, 14] and HIV-infected subjects [15, 16]. These studies demonstrated that oral administration of up to 400 mg BID for 3.5 days (healthy volunteers) and 200 mg BID for 8-10 days (healthy volunteers and HIV patients) was well-tolerated with no pattern of adverse events or clinically significant laboratory changes. These studies also demonstrated pharmacodynamic activity, with dose- and concentration-related changes in circulating white blood cells (WBCs); and a high volume of distribution (VL), suggesting high tissue penetrance.

Earlier work by some of the inventors on the mechanisms of acquired resistance to VEGF-targeted therapies, demonstrated that treatment with sunitinib treatment resulted in a marked increase in the infiltration of renal cell carcinoma (RCC) xenografts with CD11b+/Gr-1+ myeloid-derived suppressor cells (MDSC)(1). These cells have been repeatedly implicated in the development of resistance to a diverse array of anticancer therapies, including VEGF-targeted agents (2-5). The inventors further observed that the influx of MDSC, as well as the development of sunitinib resistance, could be prevented by the concurrent administration of the HDM2 antagonist MI-319 (Sanofi-Aventis), a drug whose biological effects are mediated primarily through the up regulation of p53. MDSC trafficking into tumor tissue is regulated by chemokines, many of which (e.g. SDF-1 and CXCL-12) are produced in response to hypoxia in a HIF-dependent manner. p53 is known to directly repress SDF-1 transcription (6) and the inventors have shown that MI-319 suppresses HIF-2 expression, suggesting that the drug may have both direct and indirect effects on SDF-1 expression. Based on these data, the inventors considered the possibility that MI-319 might mediate its effects on MDSC through the suppression of chemokine (e.g. SDF-1) production. Subsequent western blot analysis of tumor lysates confirmed this hypothesis.

These findings suggested that the ability of MI-319 to prevent sunitinib resistance might be due at least in part to the suppression of SDF-1 production and MDSC recruitment. To the extent that this is the case, the inventors conceived that agents that block SDF-1/CXCR4 signaling directly (e.g. AMD11070) could duplicate the effects of HDM2 blockade on MDSC trafficking and prevent sunitinib resistance.

Moreover, the inventors conceived that such a result might be achieved with comparatively little toxicity since, unlike HDM2 antagonists, CXCR4-targeted drugs would not be expected to induce cell cycle arrest in bone marrow and other normal proliferating cell populations. Accordingly, the present invention provides significant advantages in treatment outcomes utilizing the low toxicity and effects of the CXCR4 inhibitor AMD11070 (X4P-001) on MDSC trafficking, differentiation, and tumor cell gene expression in RCC.

It has now been found that CXCR4 antagonism by X4P-001 provides significant effects which may provide significant treatment benefits in patients with advanced ccRCC and other cancers by multiple mechanisms. Administration of X4P-001 decreased recruitment of MDSC, resulting in increased anti-tumor immune attack. Administration of X4P-001 additionally sustained decreases in neoangiogenesis and tumor vascular supply; and interferes with the autocrine effect of increased expression by ccRCC of both CXCR4 and its only ligand, CXCL12, thereby potentially reducing cancer cell metastasis. Administering X4P-001, a CXCR4 antagonist, sequentially (e.g. administered at the same time as separate unit dosage forms or administered as separate unit dosage forms at different times separated by up to 12 h) or concurrently (e.g. taken together) with a TKI inhibitor such as axitinib, blocks communication between the tumor and the MDSC, suppresses HIF-2α expression, reduces MDSC tumor infiltration, and appreciably improves the anti-tumor treatment effect.

In the present invention, patients with advanced forms of cancer, such as clear cell renal cell carcinoma (ccRCC) are treated with X4P-001, either as a single agent (monotherapy), or in combination with axitinib, a small molecule tyrosine kinase inhibitor (TKI) that is approved for second-line treatment of patients with ccRCC.

Without wishing to be bound by any particular theory, it is believed that by combining the two medicaments, the patients' treatment outcome can be further improved by reducing the angiogenic escape that typically occurs with TKI therapy.

In some embodiments, X4P-001, or a pharmaceutically acceptable salt thereof, is administered to a patient in a fasted state.

In some embodiments, the present invention provides a method for treating patients with cancer that presents as a solid tumor. In some embodiments, the patient has kidney cancer, renal tumor, renal carcinoma (including clear cell and papillary renal carcinoma), ovarian cancer, or melanoma.

In some embodiments, the present invention provides a method for treating refractory cancer in a patient in need thereof comprising administering X4P-001, or a pharmaceutically acceptable salt and/or composition thereof. In certain embodiments, the patient was previously administered a protein kinase inhibitor. In some embodiments, the patient was previously administered a VEGF-R antagonist. In some embodiments, the patient was previously administered a VEGF-R antagonist selected from axitinib (Inlyta) (Pfizer Inc., NY, USA), sorafenib (Nexavar® Bayer AG and Onyx); sunitinib (Sutent, Pfizer, New York, US); pazopanib (Votrient, GlaxoSmithKline, Research Triangle Park, US); cabozanitib (Cometriq, Exelexis, US); regorafenib (Stivarga, Bayer); lenvatinib (Lenvima, Eisai); bevacizumab (Avastin, Genentech, Inc. of South San Francisco, Calif.), an anti-VEGF monoclonal antibody; and aflibercept, also known as VEGF Trap (Zaltrap; Regeneron/Sanofi). Other kinase inhibitors/VEGF-R antagonists that are in development and may be used in the present invention include tivozanib (Aveo Pharmaecuticals, Cambridge, Mass.); vatalanib (Bayer, Novartis, Basel, Switzerland); lucitanib (Clovis Oncology); dovitinib (Novartis); CEP-11981 (Cephalon, US); linifanib (Abbott Laboratories, Abbott Park, US); PTC299 (PTC Therapeutics, South Plainfield, US); CP-547,632 (Pfizer); foretinib (Exelexis, GlaxoSmithKline); and motesanib (Amgen, Takeda).

In certain embodiments, the present invention provides a method for treating cancer in a patient in need thereof, wherein said method comprises administering to said patient X4P-001 in combination with a tyrosine kinase inhibitor. In certain embodiments, the X4P-001 and the tyrosine kinase inhibitor are administered simultaneously or sequentially. In certain embodiments, the tyrosine kinase inhibitor is selected from axitinib, sunitinib, sorafenib, pazopanib, cabozanitib or regorafenib. In a some embodiments of the invention, X4P-001 is administered in combination with axitinib.

Axitinib (Inlyta® Pfizer laboratories) is a kinase inhibitor. Axitinib has been shown to inhibit receptor tyrosine kinases including vascular endothelial growth factor receptors (VEGFR)-1, VEGFR-2, and VEGFR-3 at therapeutic plasma concentrations. These receptors are implicated in pathologic angiogenesis, tumor growth, and cancer progression. VEGF-mediated endothelial cell proliferation and survival were inhibited by axitinib in vitro and in mouse models. Axitinib was shown to inhibit tumor growth and phosphorylation of VEGFR-2 in tumor xenograft mouse models. Axitinib has the chemical name N-methyl-2-[3-((E)-2-pyridin-2-yl-vinyl)-1H-indazol-6-ylsulfanyl]-benzamide. The molecular formula is C₂₂H₁₈N₄OS and the molecular weight is 386.47 Daltons. The chemical structure is depicted below.

Axitinib is a white to light-yellow powder with a pKa of 4.8. The solubility of axitinib in aqueous media over the range pH 1.1 to pH 7.8 is in excess of 0.2 μg/mL. The partition coefficient (n-octanol/water) is 3.5.

Axitinib has been approved by the FDA for treatment of advanced renal cell carcinoma (RCC) after failure of one prior systemic therapy, i.e., as second line therapy. Axitinib has been tested or mentioned as a possible treatment in other oncologic indications. Accordingly, in some embodiments of the present invention, the cancer is selected from the group consisting of solid tumors (including solid fibrous tumors), neoplasms (including pancreatic, kidney, colorectal, lung, breast, thyroid and stomach neoplasms), glioblastoma, hepatocellular carcinoma or liver cancer, melanoma and intraocular melanoma, prostate cancer (including castrate-resistant prostate cancer), non-small cell lung cancer, renal tumor, renal carcinoma (including clear cell and papillary renal carcinoma) or kidney cancer, colorectal cancer, advanced gastric cancer, malignant mesothelioma, neurofibromatosis, including Schwannomatosis, soft tissue sarcoma, head and neck squamous cell carcinoma, nasopharyngeal carcinoma, adenocarcinoma, neuroendocrine carcinoma, acute myeloid leukemia, myelodysplastic syndrome, pheochromocytoma, paraganglioma, lymphoma, mantle-cell cancer, gastrointestinal-stromal tumors, or pancreatic ductal carcinoma.

In its current prescribed labeling for RCC, recommended starting oral dose of axitinib is 5 mg twice daily, approximately 12 hours apart. Depending upon individual tolerance, it is recommended that the prescribed dose of axitinib may be increased to 7 mg or 10 mg, twice daily; or reduced to 3 mg or 2 mg twice daily.

In some embodiments, the present invention provides a method for treating a refractory cancer in a patient in need thereof, wherein said method comprises administering to said patient X4P-001 in combination with a tyrosine kinase inhibitor. In some embodiments, the refractory cancer is ccRCC. In some embodiments, the refractory cancer is ccRCC and the tvrosine kinase inhibitor is axitinib.

In some embodiments, a provided method comprises administering the X4P-001, or a pharmaceutically acceptable salt thereof, is administered to a patient in a fasted state and administering the tyrosine kinase inhibitor to a patient in either a fasted or fed state.

In certain embodiments, the present invention provides a method for treating cancer in a patient in need thereof, wherein said method comprises administering to said patient X4P-001 in combination with a tyrosine kinase inhibitor, further comprising the step of obtaining a biological sample from the patient and measuring the amount of a disease-related biomarker. In some embodiments, the biological sample is a blood sample. In certain embodiments, the disease-related biomarker is circulating CD34+ cells and/or plasma levels of soluble VEGF-R.

In certain embodiments, the present invention provides a method for treating a refractory cancer in a patient in need thereof, wherein said method comprises administering to said patient X4P-001 in combination with a tyrosine kinase inhibitor, further comprising the step of obtaining a biological sample from the patient and measuring the amount of a disease-related biomarker. In some embodiments, the biological sample is a blood sample. In certain embodiments, the disease-related biomarker is circulating CD34+ cells and/or plasma levels of soluble VEGF-R.

In certain embodiments, the present invention provides a method for treating a refractory cancer in a patient in need thereof, wherein said method comprises administering to said patient X4P-001 in combination with axitinib, further comprising the step of obtaining a biological sample from the patient and measuring the amount of a disease-related biomarker. In some embodiments, the biological sample is a blood sample. In certain embodiments, the disease-related biomarker is circulating CD34+ cells and/or plasma levels of soluble VEGF-R.

In certain embodiments, the present invention provides a method for treating ccRCC in a patient in need thereof, wherein said method comprises administering to said patient X4P-001 in combination with axitinib, further comprising the step of obtaining a biological sample from the patient and measuring the amount of a disease-related biomarker. In some embodiments, the biological sample is a blood sample. In certain embodiments, the disease-related biomarker is circulating CD34+ cells and/or plasma levels of soluble VEGF-R.

In other embodiments of the invention, X4P-001 is administered in combination with a VEGF antagonist. The VEGF antagonist may be an antibody to VEGF or a VEGF trap. In certain embodiments, the VEGF antagonist is selected from bevacizumab or aflibercept.

In some embodiments, the present invention provides a method of treating cancer in a patient in need thereof, wherein said method comprises administering to said patient X4P-001 in combination with a tyrosine kinase inhibitor wherein the X4P-001 and the tyrosine kinase inhibitor act synergistically. One of ordinary skill in the art will appreciate that active agents (such as X4P-001 and a tyrosine kinase inhibitor) act synergistically when the combination of active agents results in an effect that is greater than additive. In some embodiments, the tyrosine kinase inhibitor is axitinib.

Dosage and Formulations

X4P-001 is a CXCR4 antagonist, with molecular formula C₂₁H₂₇N₅; molecular weight 349.48 amu; appearance white to pale yellow solid; solubility: X4P-001 is freely soluble in the pH range 3.0 to 8.0 (>100 mg/mL), sparingly soluble at pH 9.0 (10.7 mg/mL) and slightly soluble at pH 10.0 (2.0 mg/mL). X4P-001 is only slightly soluble in water; and melting point of 108.9° ΔC.

The chemical structure of X4P-001 is depicted below.

In certain embodiments, the composition containing X4P-001, or a pharmaceutically acceptable salt thereof, is administered orally, in an amount from about 200 mg to about 1200 mg daily. In certain embodiments, the dosage composition may be provided twice a day in divided dosage, approximately 12 hours apart. In other embodiments, the dosage composition may be provided once daily. The terminal half-life of X4P-001 has been generally determined to be between about 12 to about 24 hours, or approximately 14.5 hrs. Dosage for oral administration may be from about 100 mg to about 1200 mg once or twice per day. In certain embodiments, the dosage of X4P-0001, or a pharmaceutically acceptable salt thereof, useful in the invention is from about 200 mg to about 800 mg daily. In other embodiments, the dosage of X4P-001, or a pharmaceutically acceptable salt thereof, useful in the invention may range from about 200 mg to about 600 mg, from about 400 mg to about 800 mg, from about 600 mg to about 1000 mg or from about 800 mg to about 1200 mg daily.

In some embodiments, a provided method comprises administering to the patient a pharmaceutically acceptable composition comprising X4P-001 wherein the composition is formulated for oral administration. In certain embodiments, the composition is formulated for oral administration in the form of a tablet or a capsule. In some embodiments, the composition comprising X4P-001 is formulated for oral administration in the form of a capsule.

In certain embodiments, a provided method comprises administering to the patient one or more capsules comprising 10-1200 mg X4P-001 active ingredient; and one or more pharmaceutically acceptable excipients.

In certain embodiments, the present invention provides a composition comprising X4P-001, or a pharmaceutically acceptable salt thereof, one or more diluents, a disintegrant, a lubricant, a flow aid, and a wetting agent. In some embodiments, the present invention provides a composition comprising 10-1200 mg X4P-001, or a pharmaceutically acceptable salt thereof, microcrystalline cellulose, dibasic calcium phosphate dihydrate, croscarmellose sodium, sodium stearyl fumarate, colloidal silicon dioxide, and sodium lauryl sulfate. In some embodiments, the present invention provides a unit dosage form wherein said unit dosage form comprises a composition comprising 10-200 mg X4P-001, or a pharmaceutically acceptable salt thereof, microcrystalline cellulose, dibasic calcium phosphate dihydrate, croscarmellose sodium, sodium stearyl fumarate, colloidal silicon dioxide, and sodium lauryl sulfate. In certain embodiments, the present invention provides a unit dosage form comprising a composition comprising X4P-001, or a pharmaceutically acceptable salt thereof, present in an amount of about 10 mg, about 20 mg, about 25 mg, about 50 mg, about 75 mg, about 100 mg, about 150 mg, about 200 mg, about 250 mg, about 300 mg, about 400 mg, about 450 mg, about 500 mg, about 600 mg, about 700 mg, about 750 mg, about 800 mg, about 900 mg, about 1000 mg, about 1100 mg, or about 1200 mg. In some embodiments, a provided composition (or unit dosage form) is administered to the patient once per day, twice per day, three times per day, or four times per day. In some embodiments, a provided composition (or unit dosage form) is administered to the patient once per day or twice per day.

In some embodiments, the present invention provides a composition comprising:

-   -   (a) X4P-001, or a pharmaceutically acceptable salt thereof—about         30-40% by weight of the composition;     -   (b) microcrystalline cellulose—about 20-25% by weight of the         composition;     -   (c) dibasic calcium phosphate dihydrate—about 30-35% by weight         of the composition;     -   (d) croscarmellose sodium—about 5-10% by weight of the         composition;     -   (e) sodium stearyl fumarate—about 0.5-2% by weight of the         composition;     -   (f) colloidal silicon dioxide—about 0.1-1.0% by weight of the         composition; and     -   (g) sodium lauryl sulfate—about 0.1-1.0% by weight of the         composition.

In some embodiments, the present invention provides a composition comprising:

-   -   (a) X4P-001, or a pharmaceutically acceptable salt thereof—about         37% by weight of the composition;     -   (b) microcrystalline cellulose—about 23% by weight of the         composition;     -   (c) dibasic calcium phosphate dihydrate—about 32% by weight of         the composition;     -   (d) croscarmellose sodium—about 6% by weight of the composition;     -   (e) sodium stearyl fumarate—about 1% by weight of the         composition;     -   (f) colloidal silicon dioxide—about 0.3% by weight of the         composition; and     -   (g) sodium lauryl sulfate—about 0.5% by weight of the         composition.

In some embodiments, the present invention provides a composition comprising:

-   -   (a) X4P-001, or a pharmaceutically acceptable salt thereof—about         8-25% by weight of the composition;     -   (b) microcrystalline cellulose—about 65-85% by weight of the         composition;     -   (c) croscarmellose sodium—about 2-10% by weight of the         composition;     -   (d) sodium stearyl fumarate—about 0.1-3% by weight of the         composition; and     -   (e) colloidal silicon dioxide—about 0.05-0.7% by weight of the         composition.

In some embodiments, the present invention provides a composition comprising:

-   -   (a) X4P-001, or a pharmaceutically acceptable salt thereof—about         25-45% by weight of the composition;     -   (b) microcrystalline cellulose—about 10-35% by weight of the         composition;     -   (c) dibasic calcium phosphate dihydrate—about 15-45% by weight         of the composition;     -   (d) croscarmellose sodium—about 2-10% by weight of the         composition;     -   (e) sodium stearyl fumarate—about 0.3-2.5% by weight of the         composition;     -   (f) colloidal silicon dioxide—about 0.05-1.2% by weight of the         composition; and     -   (g) sodium lauryl sulfate—about 0.2-1.2% by weight of the         composition.

In some embodiments, the present invention provides a composition comprising:

-   -   (a) X4P-001, or a pharmaceutically acceptable salt thereof—about         35-75% by weight of the composition;     -   (b) microcrystalline cellulose—about 5-28% by weight of the         composition;     -   (c) dibasic calcium phosphate dihydrate—about 7-30% by weight of         the composition;     -   (d) croscarmellose sodium—about 2-10% by weight of the         composition;     -   (e) sodium stearyl fumarate—about 0.3-2.5% by weight of the         composition;     -   (f) colloidal silicon dioxide—about 0.05-1.2% by weight of the         composition; and     -   (g) sodium lauryl sulfate—about 0.2-1.2% by weight of the         composition.

In some embodiments, the present invention provides a composition according to Table 1 or Table 2, below.

TABLE 1 25 mg Capsule Formulation Reference to Quantity Component Standard Function (mg/capsule) % w/w X4P-001 In-House Active 25.0 14.7 Ingredient Microcrystalline NF Diluent 132.7 78.1 Cellulose Croscarmellose NF Disintegrant 10.2 6.0 Sodium Sodium Stearyl NF Lubricant 1.7 1.0 Fumarate Colloidal USP Flow Aid 0.4 0.2 Silicon Dioxide Sum Total 170.0 100.0 Hard Gelatin USP Packaging NA NA Capsules, Size 1

TABLE 2 100 mg and 200 mg Capsule Formulations 200 mg 100 mg Percent Theoretical Percent Theoretical Per Amount Per Per Amount Per Capsule Capsule Capsule Capsule Ingredients (%) (mg) (%) (mg) X4P-001 Drug 61.5 200.0 37.6 100 Substance Microcrystalline 12.9 41.93 22.9 60.9 Cellulose, NF/EP (Avicel PH 101) or equivalent Dibasic Calcium 17.8 57.85 31.7 84.3 Phosphate Dihydrate, USP/NF Croscarmellose 6.0 19.50 6.0 16.0 Sodium, NF/EP (Ac-Di-Sol) Sodium Lauryl 0.5 1.625 0.5 1.3 Sulfate, NF/Ph. Eur. Colloidal Silicone 0.3 0.9750 0.3 0.8 Dioxide, NF/Ph. Eur. (Cab-O-Sil M-5P) Sodium Stearyl 1.0 3.250 1.0 2.7 Fumarate, NF (Pruv) Total Capsule Fill 100 325.0 100 266.0

In some embodiments, the present invention provides a unit dosage form comprising a composition described above. In some embodiments, the unit dosage form is a capsule.

In as much as it may be desirable to administer a combination of active compounds, for example, for the purpose of treating a particular disease or condition, it is within the scope of the present invention that two or more pharmaceutical compositions, at least one of which contains a compound in accordance with the invention, may conveniently be combined in the form of a kit suitable for co-administration of the compositions. Thus the kit of the invention includes two or more separate pharmaceutical compositions, at least one of which contains a compound of the invention, and means for separately retaining said compositions, such as a container, divided bottle, or divided foil packet. An example of such a kit is the familiar blister pack used for the packaging of tablets, capsules and the like.

The kit of the invention is particularly suitable for administering different dosage forms, for example, oral and parenteral, for administering the separate compositions at different dosage intervals, or for titrating the separate compositions against one another. To assist compliance, the kit typically includes directions for administration and may be provided with a memory aid.

The examples below explain the invention in more detail. The following preparations and examples are given to enable those skilled in the art to more clearly understand and to practice the present invention. The present invention, however, is not limited in scope by the exemplified embodiments, which are intended as illustrations of single aspects of the invention only, and methods which are functionally equivalent are within the scope of the invention. Indeed, various modifications of the invention in addition to those described herein will become apparent to those skilled in the art from the foregoing description and accompanying drawings. Such modifications are intended to fall within the scope of the appended claims.

The contents of each document cited in the specification are herein incorporated by reference in their entireties.

EXEMPLIFICATION Example 1: Murine Models with Human Cell Lines

The effects were examined of treatment with X4P-001 and axitinib singly, and in combination on the trafficking of MDSC and other immunosuppressive cell populations and on chemokine production by RCC cells.

Mice were inoculated with 786-0 and A498 RCC xenografts, the tumors permitted to grow to ˜300 mm³, and then treatment initiated with the CXCR4 inhibitor X4P-001, axitinib, both agents in combination, or saline (control).

With each of the human cell lines, 1×107 tumor cells were implanted subcutaneously in the flanks of 36 nude/beige mice and tumors allowed to grow to roughly 7 mm in diameter. The mice were randomly divided into 4 treatment groups of 9 mice each and treated with X4P-001 (at the recommended dose), axitinib (30 mg/kg daily by gavage), both drugs, or vehicle (control). We have previously shown that MDSC tumor influx is maximal at 7 days (not shown). Therefore, on day 7, the mice were sacrificed and the tumors were measured and immediately excised and divided into three parts. One part of each tumor was paraffin-embedded for dual color immunofluorescence. Another part was mechanically disaggregated and treated with collagenase/DNAse to generate a single cell suspension for flow cytometry. The third part was frozen for future pharmacokinetic analysis. Microscope slides were made from the paraffin-embedded tumor tissue, which were stained with antibodies against CD11b, Gr-1, and FAP. The number of infiltrating CD11b+/Gr-1+ MDSC and FAP+ fibroblasts present in the tumor tissue was then determined by immunofluorescence (IF) as previously described (1).

The disaggregated tumor specimens were analyzed for CD11b+/Gr-1+ MDSC and FAP+ fibroblasts by flow cytometry. The fraction of both populations expressing CXCR4 were also determined. At the time the mice were sacrificed, the spleens were removed and cut in half. One part was disaggregated into single cell suspensions and analyzed by flow cytometry as above for MDSC. The second half was frozen for future analyses, such as PK analysis. Finally, a bone marrow (BM) sample was generated by extruding marrow from an excised femur with a syringe filled with saline and analyzed by flow cytometry for MDSC.

Results:

Whereas either drug alone either had no (axitinib) or modest (X4P-001) effects on tumor growth, the combination of X4P-001 and axitinib had additive and/or synergistic antitumor effects. Specifically, combination treatment resulted in massive tumor cell death, with the established implants actually regressing in size (See FIGS. 1A and 1B)—an effect not previously seen with VEGFR-targeted drugs given as single agents. IHC staining demonstrated, as previously, that mice treated with axitinib alone had an increase in Ki-67 positive tumor cells (See FIGS. 4A and 4C). This effect was not observed in mice that received both X4P-001 plus axitinib (See FIGS. 4A and 4C), suggesting an anti-proliferative effect of the combination. Finally, the tumors from mice receiving axitinib alone had extensive MDSC infiltration (see FIGS. 5A through 5D, whereas the tumors from mice receiving either X4P-001 alone or the axitinib/X4P-001 combination had significantly less MDSC infiltration (see FIGS. 5A through 5D).

Suppression of miRNAs mir-30a and mir-30c and Effect on HIF-2α in Xenografts:

As shown in FIG. 11, Western blots of 786 xenografts treated with X4P-001 showed reduction in the level of HIF-2α relative to that caused by axitinib treatment. Furthermore, as shown in FIGS. 12 and 13, axitinib suppressed the micro-RNAs mir-30a and mir-30c, and the addition of X4P-001 to axitinib resulted in increased mir-30a and mir-30c after 8 days of treatment (786-0 xenograft tumor). mir-30a and mir-30c microRNA and HIF-2α mRNA expression from tumors of xenografts treated with axitinib+/−X4P-001. Data is presented as mir-30a or mir-30c expression relative to the mean control value (left side) and relative HIF-2α RNA expression. FIG. 13 illustrates that axitinib and X4P-001 together act to reduce HIF-2α expression after 8 days of treatment in 786 xenograft tumors.

FIGS. 14A-C illustrate the effect of X4P-001 treatment on 786 hypoxic cells in vitro on mir-30a and mir-30c induction and HIF-2α reduction. FIG. 14A shows a Western blot of 786 cells treated with X4P-001 for 24 hours in normoxic and hypoxic (1% O₂) conditions. FIG. 14B illustrates mir-30a and mir-30c microRNA and (FIG. 14C) total HIF-2α RNA expression from the same cells from FIG. 14A.

FIG. 15A illustrates Western blot results from lysates of A375 cells or A375 cells transfected with a constitutively active Stat3 construct. Cells were treated with X4P-001 for 24 h in normoxic or hypoxic conditions. FIG. 15B shows mir-30c microRNA and FIG. 15C shows total RNA expression from the same cells from FIG. 15A. The suppression of HIF-2α and induction of mir-30a and 30c is thus dependent on Stat3 expression. Without wishing to be bound by theory, it is believed that Stat3 is important in promoting CXCL-12 mediated invasion of tumors.

What these results show is that axitinib suppressed the micro-RNAs mir-30a and mir-30c, which, without wishing to be bound by theory, are believed to inhibit HIF-2α translation. The addition of X4P-001 to axitinib in vivo and in hypoxic cells in vitro results in increased mir-30a and mir-30c.

Example 2: Further Xenograft Studies

Further studies are conducted in order to determine how treatment with X4P-001 and axitinib alone or in combination affects the distribution of MDSC and other immunosuppressive CXCR4+ cell populations (Tregs and CAF) and how CXCR4 expression by these cells affects their trafficking in tumor-bearing mice. Example 1 above is repeated with additional testing of syngeneic murine RCC Renca model and 786-M1A cells, the latter of which is a 786-0 variant known to express CXCR4 at extremely high levels (7). The studies with Renca cells are done as described above for the human cell lines except that tumors are also analyzed for CD4+/CD25bright/Foxp3+ Tregs, CD3+/CD8+ T cells in addition to MDSC and fibroblasts.

Following the procedures of Example 1, the effects of treatment with X4P-001 and axitinib on bone marrow, spleen, and tumor infiltration by CD11b+/Gr-1+MDSC, CD4+/CD25bright/Foxp3+ Tregs, CD3+/CD8+ T cells, and FAP+ cancer-associated fibroblasts (CAF) are examined and the levels of CXCR4 expression on these cells are determined.

Example 3: Cytokine and Chemokine Studies

The in vivo effects of treatment with X4P-001 and axitinib on chemokine production by RCC cells are assessed as follows:

Tumors excised from the mice undergoing treatment with X4P-001 and axitinib in Example 1 are analyzed by RT-PCR for drug-induced changes in the expression of M-CSF (CSF-1), CXCL1 (MGSA/gro-), CXCL2 (MIP-2/gro-), MIP-2/gro-, CXCL5 (ENA-78), CXCL6 (GCP-2), CXCL8 (IL-8), GM-CSF, VEGF, TNF, CCL22, and CCL28. The various ELR-containing CXCL chemokines listed are known to activate CXCR2 (8), a chemokine receptor recently implicated in MDSC recruitment (9). The cytokines VEGF, GM-CSF, and TNF are also thought to mediate MDSC chemotaxis into tumor tissue. CCL22 and CCL28 have been likewise implicated in the recruitment of Tregs (10, 11).

Numerous chemokines and other inflammatory mediators have been shown to regulate the trafficking of MDSC into tumor tissue (9, 12, 13). To determine which chemokines/cytokines are responsible for the influx of MDSC into RCC during treatment with VEGF-targeted therapies, CD11b+/Gr-1+ MDSC are isolated from the spleens of tumor-bearing mice undergoing treatment with axitinib. The MDSC are then infected with a small pooled lentiviral shRNA library (DeCode GIPZ, Thermo Scientific) for a select group of G protein-coupled and other receptors known to regulate MDSC trafficking. The library will include shRNAs for TNFR-1 and -2, IL-4R, and whole array of CXCR and CCR chemokine receptors (CXCR1-5, CCR 1-9). Several of these (e.g. CXCR-1, -2, and -4) engage chemokines known to promote MDSC recruitment (9, 12, 13).

Example 4: Pharmacokinetics Studies

In order to evaluate the pharmacokinetic properties of combined therapy with X4P-001 and axitinib, levels of X4P-001 and axitinib in blood, tumor tissue, and spleen are measured 4 hr after dosing. To measure drug levels in blood, spleen, and tumor tissue, blood is collected by ventricular puncture at the time the mice are sacrificed—4 hrs after the day 7 drug dosing. The blood samples as well as the spleen and tumor tissue are then subjected to PK analysis.

Example 5: Clinical Treatment Regimens

X4P-001 at a determined dose from 200 mg to 1200 mg daily is administered orally either once daily or twice daily in divided doses. Patients are instructed about both dosing schedule and requirements relating to food or drink near the time of dosing.

Dosing Schedule. The first daily dose is taken in the morning and the second daily dose approximately 12 hours later using the following guidelines:

-   -   Dosing should be at the same times each day ±2 hr.     -   For twice daily dosing, the interval between successive doses         should not be <9 hours nor >15 hours. If the interval would         be >15 hrs, the dose should be omitted and the usual schedule         resumed at the next dose.     -   Restrictions relating to food. Absorption is impacted by food         and patients will be instructed as follows:     -   For the morning dose         -   No food or drink (except water) after midnight until the             time of dosing         -   No food or drink (except water) for 2 hours after dosing.     -   For the second daily dose, if applicable         -   No food or drink (except water) for 1 hour before dosing         -   No food or drink (except water) for 2 hours after dosing.

Axitinib is administered consistent with prescribed labeling information. Initial treatment with axitinib is at 5 mg orally BID in addition to X4P-001 at the determined dose level. Administration of axitinib. Axitinib may be taken at the same time as axitinib. Alternatively, since axitinib has been associated with gastrointestinal adverse events and its absorption is not altered by food (see current product label), patients may, with the approval of their clinician, take the axitinib separately, following the same BID dosing schedule guidelines noted.

Dosing of X4P-001 and/or axitinib may be adjusted by the clinician as appropriate. The dose of X4P-001 and/or axitinib may be lowered according to the judgment of the clinician. If a patient receiving X4P-001 in combination with axitinib experiences an adverse event at Grade >2, the dose of X4P-001 and/or axitinib may be lowered according to the judgment of the clinician. If a patient successfully completes the first 4 weeks of treatment, that is, without experiencing any adverse events greater than Grade 2, the daily dose of X4P-001 and/or axitinib may be increased. consistent with the judgment of the clinician.

Evaluation of Response to Treatment and Disease Status

Classification of tumor response may be performed according to codified tumor response evaluation, according to the Response Evaluation Criteria in Solid Tumors Group (“RECIST”), as described in Therasse et al. (2000), J. National Cancer Institute, 92:205-216. Radiologic assessment of ccRCC is accomplished by Computed Tomography (CT) with slice thickness ≤5 mm and contrast. CT is performed prior to treatment (baseline) and may be made at intervals during treatment to determine the response.

Key Terminology

Measurable non-nodal lesions—≥10 mm in longest diameter.

Measurable nodal lesions—≥15 mm in short axis

Nonmeasurable lesions—lesions that are smaller, including those that cannot be measured.

Measurable disease—presence of at least one measurable lesion.

Target Lesions

At baseline, four (4) measureable lesions, two (2) for each individual organ, are identified, documented, and the appropriate diameter of each is recorded. If measurable extra-renal lesions are present, a measurable extra-renal lesion is also identified, documented, and the appropriate diameter is recorded. Lesions are selected based on size, to be representative of disease, and suitable for reproducible repeat measurement. Target lesions may include measurable lymph nodes.

During treatment, each target lesion is assessed for Complete Response, Partial Response, Stable Disease, or Progressive Disease as follows:

Complete Response (CR)

-   -   (a) Disappearance of all non-nodal lesions, and     -   (b) Absence of pathologic lymph nodes^(a).

Partial Response (PR)

-   -   (a) ≥30% decrease from baseline in the SOD of the target lesions         Stable Disease (SD)     -   (a) Persisting disease that does not meet criteria for either PR         or PD Progressive Disease (PD)     -   a) ≥20% increase in the SOD of the target lesions, compared to         the smallest sum, which may be either at baseline or while on         treatment; and     -   (b) an absolute increase of ≥5 mm in the SOD.

Non-Target Lesions

All other lesions present at baseline, including pathologic nodes (defined as nodes >10 mm in short axis) should be documented (quantitative measurements are not required) so that they can be classified on follow-up as present, absent, or unequivocal progression.

Complete Response (CR)

-   -   (a) Disappearance of all non-target lesions, and     -   (b) Absence of pathologic lymph nodes^(a).

Non-CR/Non-PD

-   -   Persistence of one or more non-target lesions

Progressive Disease (PD)

-   -   Unequivocal progression of existing non-target lesions.

[Note: ^(a)=All lymph nodes, whether or not designated target or non-target lesions, have short axis diameter ≤10 mm.]

New Lesions

A new lesion should be unequivocal (e.g., not attributable to variation in technique); includes lesions in a location not scanned at baseline.

Pharmacokinetic Assessments

If desired, pharmacokinetic assessment of blood samples for plasma levels of X4P-001 and axitinib may be conducted. Blood samples are collected as scheduled. Samples are analyzed for X4P-001 concentration using reversed-phase high performance liquid chromatography (RP-HPLC) with MS/MS detection. The validated range of this bioanalytic method is 30 to 3,000 ng/mL in plasma.

Pharmacokinetic assessment of axitinib may be accomplished using techniques such as described in Tortorici et al., (2011) Invest. New Drugs 29:1370-1380, the full disclosure of which is hereby specifically incorporated herein by reference.

Example 6: Formulation Trial Results for X4P-001

This Example summarizes pilot trial results on chosen formulation for each of the 3 dose strengths for X4P-001. The powder blend containing AFT, fillers/diluents, a disintegrant, a glidant and a lubricant was prepared and filled into size 1 hard gelatin capsules on an automated capsule filling machine. The process developed for all 3 formulations showed adequate flowability, acceptable weight variation and content uniformity. All 3 formulations showed more than 90% release after 45 minutes dissolution test. Amber glass bottles, each containing 30 capsules, polyester coils and one desiccant pack, were individually sealed in aluminum foil bags and placed on stability testing under 2 storage conditions (2-8° C. and 25° C./60% RH).

Introduction

A total of 9 formulations (3 for each of the 3 dose strengths for X4P-001) were prepared and manually filled into size 1 hard gelatin capsules. The best capsule formulation of X4P-001 for each dose level was selected from three (3) formulation candidates based on 1-month R&D stability data (Table 3). The chosen formulation for each dose level was scaled-up for blending and capsule filling using V-blender and automated capsule filler, respectively.

The objectives of the pilot trial were: 1) to confirm the stability of the chosen formulations for X4P-001 10 mg, 25 mg and 100 mg capsules using a new lot of X4P-001; and 2) to collect information on scale up and the new process used for making X4P-001 capsules.

Materials and Equipment List of Materials

X4P-001, lot #2893-A-3P

Microcrystalline Cellulose, NF, Avicel® PH-101, Lot #1155

Dibasic Calcium Phosphate Dihydrate, USP, Emcompress®, Lot # B10E

Croscarmellose Sodium, NF, Ac-Di-Sol®, Lot # T050N

Colloidal Silicon Dioxide, USP, Cab-O-Sil® M-5P, Lot #1J021

Sodium Stearyl Fumarate, NF, PRUV™, Lot #30001902

Sodium Lauryl Sulfate, NF, Lot #12810

Empty Hard Gelatin Capsules, Size 1 White Opaque, Lot #582410

60 cc Amber Glass Bottles, with a green screw-on cap

Silica Gel Desiccant Pouches, 0.5 g

Rayon Coil 12-gram/y

2×3 3-Spot Humidity Indicator Card, Lot #10018

Aluminum Foil Bags MIL-PRF-131J

List of Equipment

2-Qt. V-Blender

Bonapace In-Cap Capsule Filling Machine

Pouch Sealer

Tap Density Tester

Particle Size Analyzer (Sonic Sifter)

Experimental and Results Selection of Formulation for the Pilot Trial

One formulation (10-E, 25-E and 100-F) was chosen for the pilot X4P-001 trial at each of the 10 mg, 25 mg and 100 mg dose levels. The selection of the formulation was mainly based on the 1-month stability profile of the 3 formulations for each dose under 2 storage conditions (25° C./60% RH and 2-8° C.) (Table 3). None of the formulations were stable under the 40° C./75% RH storage condition.

Only Avicel® serves as a diluent/filler in both 10 mg and 25 mg formulations. To facilitate the capsule filling process on an automated capsule filler, a glidant such as colloidal silicon dioxide (Cab-O-Sil®) was explored for addition to the formulation. The trial on 2 placebo batches confirmed that the Cab-O-Sil® helps to reduce the weight variation of capsules (Table 4). Cab-O-Sil® was also added to the 100 mg formula (100-F) that contains both Avicel® and Emcompress® to ensure adequate flow of the powder blend.

In-Process Testing

A total of 3 formulations (1 for each of the 3 dose strength for X4P-001) were prepared. The powder blend was filled into size 1 hard gelatin capsules on In-Cap Capsule Filling Machine. The weight of the filled capsules showed about 1% in weight variability (RSD) (Table 5).

Initial Testing on Final Products

The average capsule fill weight of all batches was well within 1% of the target. The composite assay test results for batches #1191-10-PP, 1191-25-PP and 1191-100-PP were 98.8%, 99.0% and 99.9% respectively (Table 6).

The blend uniformity of all batches was evaluated using the USP Content Uniformity test. The content uniformity of the powder blend met the required 6% RSD (Table 6).

The dissolution test on 6 capsules from each batch was performed per USP dissolution method. All batches showed more than 99% drug release at 45 minutes (Table 6).

Stability Testing

Twenty (20) amber glass bottles each containing 30 capsules, appropriate amount of polyester coils and one desiccant pack were individually sealed in aluminum foil bags and placed on stability testing under 2 storage conditions (24° C. and 25° C./60% RH) per Pilot Stability Protocol (Table 8). One humidity indicating card was included in each aluminum foil bag for testing the seal of each sample.

Physical Properties of X4P-001 and the Powder Blend

Particle size distribution of X4P-001 is shown in Table 9 and FIG. 16. The results of bulk density, tap density and Carr's Index are summarized in Table 7. The physical properties of the low strength blend for the 10 and 25 mg formulation were comparable to the R&D batches. However, the powder blend of the 100 mg batch showed lower bulk and tap density due to differences in two lots of X4P-001. The new lot is more bulky than the previous lot.

CONCLUSIONS

Three (3) pilot stability batches were successfully manufactured for the active pharmaceutical ingredient (“API”), X4P-001. The current process for all three dose levels is recommend for supporting the manufacturing of upcoming clinical batches. As used herein and in the following Tables, “API” refers to X4P-001. “API” is an abbreviation for “active pharmaceutical ingredient” that is commonly used in the art.

TABLE 3 Summary of 1-Month Stability Results on Chosen R&D Batches Batch Information LOT NO. 1191-10-E 1191-25-E 1191-100-F Param- 25° C./ 25° C./ 25° C./ eters 2-8° C. 60% RH 2-8° C. 60% RH 2-8° C. 60% RH API 10 25 100 (mg) Batch 175 175 250 Size (g) Dissolution % at 112 110 91 95 99 96 45 min. Assay @ 1-month % LC 105.5 110.5 99.2 100.7 94.1 91.5 Related Substances Tot. % 2.0 2.2 2.0 2.3 0.9 1.2 Area Assay @ time zero* % LC 99.4 100.9 94.0 Related Substances* Tot. % 0.4 0.7 94.0 Area *The time zero data were included as reference

TABLE 4 Summary of Weight Variation Results on X4P-001 Capsules from Pilot Trials Batch Information PILOT BATCH LOT NO. Place- Place- 1191- 1191- 1191- 1191- Parameters bo-1 bo-2 100-H 10-P 25-P 100-P API (mg) 0 0 100 10 25 100 Batch Size 200 200 200 650 650 1200 (g) Formulation API % 0.0 0.0 37.6 6.0 14.7 37.6 Avicel % 92.8 92.5 22.9 86.7 78.1 22.9 Emcomp. % 0.0 0.0 31.7 0.0 0.0 31.7 Ac-Di-Sol % 6.3 6.3 6.0 6.0 6.0 6.0 Cab-O-Sil % 0.00 0.25 0.23 0.25 0.24 0.30 PRUV % 1.0 1.0 1.0 1.0 1.0 1.0 SLS % 0.0 0.0 0.5 0.0 0.0 0.5 TOTAL % 100.1 100.1 99.9 100.0 100.0 100.0 Weight Statistics N 20 20 20 20 20 20 MIN 225.7 219.9 296.0 234.1 236.9 334.1 MAX 271.3 252.8 355.9 248.5 251.0 349.6 MEAN 250.6 244.6 339.0 241.9 245.0 341.0 SD 11.9 7.8 14.8 3.6 3.6 4.3 Weight Variation RSD 4.8% 3.2% 4.4% 1.5% 1.5% 1.3% Wt. Var. w/o outliers N 19 19 18 N/A MEAN 251.9 245.9 343.3 RSD 4.2% 2.2% 2.0%

TABLE 5 Summary of In-Process Weight Check Results on X4P-001 Capsules LOT NO. Batch Information Parameters 1191-10-P 1191-25-P 1191-100-P API (mg) 10 25 100 Batch Size (g) 650 650 1200 Weight Statistics N 11 10 11 → MIN 239.5 239.0 336.9 MAX 245.0 249.0 344.8 MEDIAN 242.1 245.5 341.7 MEAN 242.5 245.1 341.6 SD 1.7 3.0 2.3 Weight Variation RSD 0.7% 1.2% 0.7% → Capsule Wt.** → 1 241.9 244.9 339.9 2 244.6 245.7 341.7 3 245.0 249.0 336.9 4 241.5 245.9 344.8 5 242.1 247.3 343.3 6 242.1 239.0 342.9 7 240.7 242.7 341.9 8 244.6 245.3 344.3 9 242.9 242.9 341.7 10 242.1 248.7 338.9 11 239.5 340.8 **Average weight of 10 capsule samples, taken every 10 minutes during encapsulation.

TABLE 6 Summary of Time Zero Results on Pilot Stability Batches LOT NO. Batch Information Parameters 1191-10-PP 1191-25-PP 1191-100-PP API (mg) 10 25 100 Batch Size 650 650 1200 (g) Target Fill 167 170 266 Wt. (mg) Wt. Var. MEAN 241.9 245.0 341.0 Capsules → RSD 1.5% 1.5% 1.3% Fill Wt. MEAN 168 171 267 Capsules → Content MEAN 96.9% 95.8% 99.9% Uniformity → RSD 2.2% 2.3% 5.2% Dissolution → % at 45 min. 99.6% 100.8% 99.7% Assay → % LC 98.8% 99.0% 99.9% Related Tot. % Area 1.4% 1.4% 1.5% Substances →

TABLE 7 Comparison of Physical Properties of Powder Blends of R&D Batches Physical Parameters Dev. Batches Pilot Batches 10 mg Batches → 1191-10-E 1191-10-P Bulk Density (g/cc) 0.34 0.36 Tap Density (g/cc) 0.53 0.51 Carr's Index (%) 36% 28% Mean PS (um) n/a 50    25 mg Batches → 1191-25-E 1191-25-P Bulk Density (g/cc) 0.36 0.36 Tap Density (g/cc) 0.55 0.52 Carr's Index (%) 34% 32% Mean PS (um) n/a 54    100 mg Batches → 1191-100-F 1191-100-P Bulk Density (g/cc) 0.8  0.62 Tap Density (g/cc) 1.08 0.84 Carr's Index (%) 26% 26% Mean PS (um) n/a 85   

TABLE 8 Pilot Stability Protocol PACKAGING INFORMATION: Amber 60 cc glass bottle (sealed in aluminum foil bag) Cap/Closure Type Green plastic screw-on top Number of Bottles Packaged 15 bottles from each batch Number of Capsules Per Bottle 30 capsules (with polyester coils and 1 desiccant pack) STORAGE CONDITIONS: Total Number of Storage Conditions Time Points Bottles A Ambient Temperature Stability Time Zero 2 + 1** B 25° C. + 2° C./60% + 1M, 3M 2 + 2** 5% RH C 2° C.-8° C. 1M, 3M 2 + 2** Totals 11 TESTING TO BE COMPLETED AT EACH TIME POINT: Acceptance No. Test Method Performed By Criteria 1. Appearance Visual Analytical Lab Record results 2. Content HPLC Analytical Lab USP Uniformity Requirements (initial time <905> zero only) 3. Assay HPLC Analytical Lab Record results 4. Dissolution USP Analytical Lab Record results Apparatus 2 5. Odor Olfactory Formulation Record results **Additional back-up bottles for all conditions.

TABLE 9 Particle Size Distribution Product: X4P-001 Free Base Lot#: 2893-A-3P Date: 10 Jan. 2003 Sample Wt.: 5 grams Testing Time: 5 minutes # Mesh Size Par. Size (μm) % Retained 40 425 1.3 60 250 2.5 80 180 5.8 100 150 37.8 170 90 36.1 270 53 13.8 Pan <53 2.7 Sum: 100.0

Example 7: Development and Formulation of 200 me Capsule

This Example describes the development of a 200 mg strength of X4P-001 Capsules and process development activities.

The formulation for X4P-001 Capsules, 100 mg was employed as a baseline for the proposed 200 mg formulation. The goal of the formulation development activities was to obtain a higher dosage form of API with a similar dissolution profile to the 100 mg strength and manufacture the product in a size 1 gelatin capsule.

A feasibility batch was manufactured using a prototype capsule formulation (developed by Metrics) based on the excipients used in the 100 mg CTM batch formulation as shown in Table 10 below. This feasibility batch met all previously established drug product specifications and displayed a drug release similar to the 100 mg strength CTM batch (15K227). The goal of the X4P-001 Capsules, 200 mg formulation development activities was to identify an acceptable capsule formulation to be deployed in Phase 1 clinical studies and advanced into subsequent clinical study phases as appropriate using a scalable formulation and manufacturing process using a size 1 gelatin capsule, consistent with the current strengths (25 mg and 100 mg) of the subject product line.

TABLE 10 Formulation of 200 mg and 100 mg Capsules 200 mg Strength 100 mg Strength Percent Theoretical Percent Theoretical Per Amount Per Per Amount Per Capsule Capsule Capsule Capsule INGREDIENTS (%) (mg) (%) (mg) X4P-001 Drug 61.5 200.0 37.6 100.0 Substance Microcrystalline 12.9 41.93 22.9 60.9 Cellulose, NF/EP (Avicel PH 101) or equivalent Dibasic Calcium 17.8 57.85 31.7 84.30 Phosphate Dihydrate, USP/NF Croscarmellose 6.0 19.50 6.0 16.00 Sodium, NF/EP (Ac-Di-Sol) Sodium Lauryl 0.5 1.625 0.5 1.300 Sulfate, NF/Ph. Eur. Colloidal Silicone 0.3 0.9750 0.3 0.8000 Dioxide, NF/Ph. Eur. (Cab-O-Sil M-5P) Sodium Stearyl 1.0 3.250 1.0 2.700 Fumarate, NF (Pruv) Total Capsule Fill 100.0 325.0 100.0 266.0 Capsules, Empty, 1 Capsule 1 Capsule Hard Gelatin Size 1 White/White

One feasibility batch was prepared using the formulation outlined in Table 10 above. Feasibility batch manufacturing equipment included: V-shell blender (4 quart), 30 mesh hand screen, and MF-30 Manual Capsule Filler. The manufacturing process for each batch is described below and depicted in FIG. 8. The batch manufacture process utilized the same process train as the current 100 mg strength.

1. Add the X4P-001 active ingredient to the 4 quart V-Blender.

2. Sift Avicel PH-101 and Dibasic Calcium Phosphate through a 30 mesh hand screen and add to the 4 quart V-blender. Mix for 4 minutes (100 rotations).

3. Sift Croscarmellose Sodium and Sodium Lauryl Sulfate through a 30 mesh hand screen and add to the 4 quart V-Blender. Mix for 2 minutes (50 rotations).

4. Sift Colloidal Silicon Dioxide through a 30 mesh hand screen and add to the 4 quart V-Blender. Mix for 2 minutes (50 rotations).

5. Discharge blended materials from the 4 quart V-Blender and sift through a 30 mesh screen. Transfer screened material back to the 4 quart V-Blender and mix for 2 minutes (50 rotations).

6. Sift Sodium Stearyl Fumarate through a 30 mesh hand screen and add to the 4 quart V-Blender. Mix for 3 minutes (75 rotations).

7. Encapsulate the blended material using an MF-30 Manual Capsule Filler to a target weight of 325.0 mg/capsule.

The completed final blend was encapsulated using an MF-30 Manual Capsule Filler, filled capsule properties are presented in Table 11, below.

TABLE 11 X4P-001 Capsules, 200 mg Capsule Fill Weight Batch 15/858-034 Capsule Parameter (X4P-001 Capsules, 200 mg) Tray 1 Average Weight 319.1 mg Tray 2 Average Weight 320.1 mg Tray 3 Average Weight 327.6 mg Individual Max 350.6 mg Individual Min 298.1 mg RSD (%) 3.5

Following completion of the encapsulation activities a single capsule was filled using the MF-30 manual encapsulation to determine the maximum fill weight that could be filled into a size 1 capsule using the remaining finished blend. A fill weight of 425.0 mg was obtained during execution of the activity.

The conclusion of the encapsulation process development effort showed that encapsulation is a viable operation for processing the product.

Analytical Results of X4P-001 Capsules, 200 mg Feasibility Batch.

Feasibility batch 15/858-034 was tested for Assay/Related Substances, Moisture, Dissolution, and Content Uniformity. Results of this testing are shown in FIGS. 9 and 10. The result of the assay testing was 97.4% of label claim with total impurities of 0.75% and a moisture value of 3.9% w/w.

Comparison of the dissolution profile results of the 200 mg formulation composition compared to the 100 mg formulation CTM batch (15K227) is presented in FIG. 10. The proposed 200 mg formulation compared favorable to the current 100 mg formulation with an f₂ similarity factor of 83.

REFERENCES

-   1. Panka D J, Liu Q, Geissler A K, Mier J W. HDM2 antagonism delays     the development of sunitinib resistance in RCC xenografts: Effects     of MI-319 on sunitinib-induced p53 activation, SDF-1 induction, and     tumor infiltration by CD11b+/Gr-1+ myeloid suppressor cells. Mol     Cancer 2013; 12: 17. -   2. Shojaei F, Wu X, Malik A K, Zhong C, Baldwin M E, Schanz S, Fuh     G, Gerber H P, Ferrara N. Tumor refractoriness to anti-VEGF     treatment is mediated by CD11b+Gr1+ myeloid cells. Nature Biotech     2007; 25: 911-20. -   3. Zea A H, Rodriguez P C, Atkins M B, Hemandez C, Signoretti S,     Zabaleta J, McDermott D, Quiceno D, Youmans A, O'Neill A, Mier J,     Ochoa A C. Arginase-producing myeloid suppressor cells in renal cell     carcinoma patients: a mechanism of tumor evasion. Cancer Res 2005;     65: 3044-8. -   4. Nagaraj S, Gupta K, Pisarev V, Kinarsky L, Sherman S, Kang L,     Herber D L, Schneck J, Gabrilovich D I. Altered recognition of     antigen is a mechanism of CD8+ T cell tolerance in cancer. Nat Med     2007; 13: 828-35. -   5. Finke J, Ko J Rini B, Rayman P, Ireland J, Cohen P. MDSC as a     mechanism of tumor escape from sunitinib mediated anti-angiogenic     therapy. Int Immunopharmacol 2011; 11: 856-61. -   6. Moskovits N, Kalinkovich A, Bar J, Lapidot T, Oren M. p53     attenuates cancer cell migration and invasion through repression of     SDF-1/CXCL12 expression in stromal fibroblasts. Cancer Res 2006; 66:     10671-6. -   7. Vanharanta S, Shu W, Brenet F, Hakimi A A, Heguy A, Viale A,     Reuter V E, Hsieh J J-D, Scandura J M, Massague J. Epigenetic     expansion of VHL-HIF signal output drives multiorgan metastasis in     renal cancer. Nat Med 2013; 19: 50-6. -   8. Gale L M, McColl S R. Chemokines: extracellular messengers for     all occasions?BioEssays 1999; 21: 17-28. -   9. Highfill S L, Cui Y, Giles A J, Smith J P, Zhang H, Morse E,     Kaplan R N, Mackall C L. Disruption of CXCR2-mediated MDSC tumor     trafficking enhances anti-PD1 efficacy. Sci Transl Med 2014; 6:     ra67. -   10. Facciabene A, Peng X, Hagemann J S, Balint K, Barchetti A, Wang     L-P, Gimotty P A, Gilks C B, Lal P, Zhang L, Coukos G. Tumour     hypoxia promotes tolerance and angiogenesis via CCL28 and Treg     cells. Nature 2011; 475: 226-230. -   11. Montane J, Bischoff L, Soukhatcheva G, Dai D L, Hardenberg G,     Levings M K, Orban P C, Kieffer T J, Tan R, Verchere C B. Prevention     of murine autoimmune diabetes by CCL22-mediated Treg recruitment to     pancreatic islets. J Clin Invest 2011; 121: 3024-8. -   12. Acharyya S, Oskarsson T, Vanharanta S, Malladi S, Kim J, Morris     P G, Monava-Todorova K, Leversha M. Hogg N, Seshan V E, Norton L,     Brogi E, Massague J. A CXCL1 paracrine network links cancer     chemoresistance and metastasis. Cell 2012; 150: 165-78. -   13. Zhao X, Rong L, Zhao X, Xiao L, Liu X, Deng J, Wu H, Xu X, Erben     U, Wu P, Syrbe U, Sieper J, Qin Z. TNF signaling drives     myeloid-derived suppressor cell accumulation. J Clin Invest 2012;     122: 4094-4104. -   14. Silva J M, Marran K, Parker J S, Silva J, Golding M, Schlabach M     R, Elledge S J, Hannon G J, Chang K. Profiling essential genes in     human mammary cells by multiplex RNA1 screening. Science 2008; 319:     617-20. -   15. Schlabach M R, Luo J. Solimini N L, Hu G, Xu Q, Li M Z, Zhao Z,     Smogorzewska A, Sowa M E, Ang X L, Westbrook T F, Liang A C, Chang     K, Hackett J A, Harper J W, Hannon G J, Elledge S J. Cancer     proliferation gene discovery through functional genomics. Science     2008; 319: 620-24. -   16. Shen H B, Gu Z Q, Jian K, Qi J. CXCR4-mediated STAT3 activation     is essential for CXCL12-induced invasion in bladder cancer. Tumour     Biol 2013; 34: 1839-45. -   17. Tu S P, Jin H, Shi J D, Zhu L M, Suo Y, Liu G, Liu A, Wang T C,     Yang C S. Curcumin induces the differentiation of myeloid-derived     suppressor cells and inhibits their interaction with cancer cells     and related tumor growth. Cancer Prev Res 2011; 5: 205-15. -   18. Husain Z, Huang Y, Seth P J, Sukhatme V P. Tumor-derived lactate     modifies antitumor immune response: Effect on myeloid-derived     suppressor cells and NK cells. J Immunol 2013; 191: 1486-95. 

We claim:
 1. A method for treating cancer in a patient in need thereof, wherein said method comprises administering to said patient X4P-001, or a pharmaceutically acceptable salt thereof in combination with a tyrosine kinase inhibitor.
 2. The method of claim 1, wherein the cancer is refractory.
 3. The method of claim 1 or 2, wherein the patient has previously been treated with a tyrosine kinase inhibitor and wherein the patient has exhibited resistance to the tyrosine kinase inhibitor via angiogenic escape.
 4. The method of any one of claims 1-3, wherein the cancer is selected from advanced renal cell carcinoma (RCC), clear cell renal carcinoma (ccRCC), or papillary renal carcinoma.
 5. The method of any one of claims 1-4, wherein the cancer is ccRCC.
 6. The method of any one of claims 1-5, wherein the tyrosine kinase inhibitor is selected from axitinib, sunitinib, sorafenib, pazopanib, cabozanitib, or regorafenib; or a pharmaceutically acceptable salt thereof.
 7. The method of any one of claims 1-6, wherein the tyrosine kinase inhibitor is axitinib, or a pharmaceutically acceptable salt thereof.
 8. The method of any one of claims 1-7, wherein the patient is treated with X4P-001, or a pharmaceutically acceptable salt thereof, in an amount effective to reduce angiogenic escape, and then the patient receives additional treatment with a tyrosine kinase inhibitor.
 9. The method of any one of claims 1-8, wherein the X4P-001, or a pharmaceutically acceptable salt thereof, and the tyrosine kinase inhibitor act synergistically.
 10. The method of any one of claims 1-9, wherein tumor cells taken from the patient exhibit increased expression of Ki-67 after previous treatment with the tyrosine kinase inhibitor.
 11. The method of any one of claims 1-10, wherein a tumor sample taken from the patient exhibits an increase in number of myeloid-derived suppressor cells after previous treatment with the tyrosine kinase inhibitor.
 12. The method of any one of claims 1-11, wherein a tumor sample taken from the patient exhibits increased infiltration area of the tumor by myeloid-derived suppressor cells after previous treatment with the tyrosine kinase inhibitor.
 13. The method of any one of claims 1-12, further comprising the step of obtaining a biological sample from the patient and measuring the amount of a disease-related biomarker.
 14. The method of claim 13, wherein the biological sample is a blood sample.
 15. The method of claim 14, wherein the disease-related biomarker is circulating CD34+ cells and/or plasma levels of soluble VEGF-R.
 16. The method of any one of claims 1-15, wherein the X4P-001, or a pharmaceutically acceptable salt thereof, is administered orally twice per day.
 17. The method of claim 16, wherein the daily dose of X4P-001, or a pharmaceutically acceptable salt thereof, is from about 200 mg to about 1200 mg.
 18. A method for reducing resistance to treatment with a tyrosine kinase inhibitor in a patient receiving said treatment, said method comprising administering to said patient X4P-001, or a pharmaceutically acceptable salt thereof, in an amount effective to reduce angiogenic escape.
 19. A method for treating refractory ccRCC in a patient in need thereof, comprising the step of administering to the patient an effective amount of X4P-001, or a pharmaceutically acceptable salt thereof, in combination with a tyrosine kinase inhibitor.
 20. The method of claim 18 or 19, wherein the tyrosine kinase inhibitor is selected from axitinib, sunitinib, sorafenib, pazopanib, cabozanitib, or regorafenib; or a pharmaceutically acceptable salt thereof.
 21. The method of claim 18 or 19, wherein the tvrosine kinase inhibitor is axitinib, or a pharmaceutically acceptable salt thereof.
 22. The method of claim 18 or 19, wherein the X4P-001, or a pharmaceutically acceptable salt thereof, and the tyrosine kinase inhibitor act synergistically.
 23. The method of claim 18 or 19, wherein the X4P-001, or a pharmaceutically acceptable salt thereof, is administered orally twice per day.
 24. The method of claim 23, wherein the daily dose of X4P-001, or a pharmaceutically acceptable salt thereof, is from about 200 mg to about 1200 mg. 